Elyn R. Saks is a lawyer and a professor at the University of Southern California Gould School of Law. In a book aptly titled The Center Cannot Hold,1 she tells how she managed to achieve this goal in spite of a chronic mental illness that was diagnosed, at different times, as paranoid schizophrenia and schizoaffective disorder, depressive type.
Elyn grew up in Miami, Florida, graduated from Vanderbilt, received a B Phil from Oxford, and a law degree from Yale—all with the highest distinction. This in spite of her struggle with a hydra-headed psychosis that came and went but never went away, and a “center” that disintegrated again and again, after being temporarily restored with the help of therapy, friendship, work, and psychotropic medication.
The first indications that Elyn might be heading for a difficult psychological life came while she was an undergraduate at Vanderbilt. Her anxiety was constant, although less while doing academic work, from which she drew most of her identity. Away from home, faced with new challenges and new expectations, Elyn began to “unravel.” She describes herself as “frantic during the day, sleepless during the night,”1p46 and she found it hard to concentrate and to think clearly. This daughter of fastidious professional parents let her hygiene slip, even as she realized that her body “stank.”
“My best guess,” she writes of that time, “is that my illness was beginning to poke through the shell (for lack of a better word) that helped me, indeed helps all of us, maintain a separation between what is real and what is not. For the next few years, that’s where things would precariously balance—me unwittingly trying to keep the shell strong, and my illness trying equally hard to break through.”1p40 In this psychic tug of war, substance abuse was not a contributing factor. Unlike many patients who begin to show signs of a major mental illness at her age, Elyn did not abuse drugs or alcohol.
In spite of a psyche that was increasingly blurring the boundaries between fantasy and reality, Elyn graduated from Vanderbilt with a perfect academic record, was named class valedictorian and won a Marshall scholarship to study ancient philosophy at Oxford—where her life really began to fall apart. There were trips to the emergency room, stays in psychiatric hospitals, psychiatrists and psychoanalysts, and psychotropic medications.
At Oxford, Elyn continued to excel academically even as reality became a tougher slog, and she retreated further into her fantasy world. She did not feel herself to be real, live, and continuous as R. D. Laing characterized the grounding of the ontologically secure person in The Divided Self.2 Nor did she experience others as real, live, and continuous. It was as if she lived behind a wall of glass—Silvia Plath’s bell jar comes to mind—cutting her off from what was going on around her. Elyn became frustrated and angry in her isolation and turned that anger against others, seeing ulterior motives where there were none. In fact, she had a coterie of loyal friends, teachers, and colleagues.
In her dreams, Elyn killed these friends, teachers, and colleagues because she was able to trick herself into believing that they wanted to kill her. This “killing” was how she feigned control when in fact she had ceded control to her illness, or her illness had taken it from her (most likely, it worked both ways). Elyn was self-deceived, depressed, paranoid, and psychotic much of the time:
Psychosis is like an insidious infection that nevertheless leaves some of your faculties intact; in a psychiatric hospital, for example, even the most debilitated schizophrenic patients show up on time for meals, and they evacuate the ward when the fire alarm goes off. So it was for me. Completely delusional, I still understood essential aspects of how the world worked. For example, I was getting my schoolwork done, and I vaguely understood the rule that in a social setting, even with the people I most trusted, I could not ramble on about my psychotic thoughts. To talk about killing children, burning whole worlds, or being able to destroy cities with my mind was not part of polite conversation.
At times, though, I was so psychotic that I could barely contain myself. The delusions expanded into full-blown hallucinations, in which I could clearly hear people whispering. I could hear my name being called when no one was physically around—in a corner of the library, or late at night, in my bedroom where I slept alone.1pp98-99
While at Oxford, Elyn became the patient of a Kleinian psychoanalyst—Mrs Jones—with whom she formed a strong therapeutic alliance, and whom Elyn credits with being the “glue” that held her together, if precariously: “I was falling apart, flying apart, exploding—and she gathered my pieces and held them for me.”1p98 After 3 years of intense psychoanalytic work, and finishing her B Phil, again with high distinction, Elyn considered staying in England to continue therapy. But Mrs Jones encouraged her to return home. As expected with someone of Elyn’s psychic fragility, the prospect of losing this alliance induced great anxiety and led to a regression:
I go to my session. I threaten Mrs Jones with a knife. I am very psychotic and out of control. Mrs Jones is kind and gentle. She asks me for the knife and I give it to her. I start screaming. I throw myself against the wall. Mrs Jones and her husband restrain me. The ambulance arrives and takes me to the hospital. I become out of control again and am subdued. I am crying and sobbing that I will be leaving Mrs Jones . . . . Mrs. Jones had been the glue that held me together. With that glue soon to be gone, would I not shatter into a thousand pieces? The anxiety was overwhelming, and our sessions became more intense and hallucinatory.1p110
Elyn: You can’t leave. I won’t let you. Plupenitenary issues must be addressed. That’s a dress. Come home with me, please?
Mrs Jones: I think, you see, that you make yourself confused because you want to avoid the pain of separation. It’s upsetting to think I have a life of my own, apart from you. You are trying to live inside me.1p111
Elyn has fused with Mrs Jones by obliterating the person-to-person boundaries that nonpsychotic persons observe. She has crossed a line in her attempt to become the person who has provided the “glue” that allowed her to have a fledgling, brittle center of self. Note the neologism plupenitenary and the clang association addressed/dress, which are indications of formal thought disorder—an upshot of the psychotic mind’s need to create different words and different links between words.
While psychotic, Elyn was mostly lost to the world of reality, and had no insight. During a stable interval, she looked back on what that was like for her: “With psychosis, the wall that separates fantasy from reality dissolves; inside my head, the fantasies were real, and everything was actually happening. The images I saw, the actions I took, were all real, and it made me frantic.”1p111
After graduation, Elyn left Oxford and Mrs Jones, returned to Miami and stayed with her parents until fall when she moved to New Haven to begin law school at Yale—where she continued her pattern of academic excellence and periodic ontic collapse. Her psychotic episodes became more severe and bizarre, requiring physical restraint and, eventually, her first antipsychotic medication, which she strenuously resisted verbally and physically. During the next few years, this drug (unnamed in the book), was replaced in turn by perphenazine, thiothixene, olanzapine, and clozapine, as eventual inefficacy and adverse effects demanded a change.
No drug completely erased Elyn’s psychotic symptoms, but each, for a time, lessened these symptoms and their impact, allowing her to finish law school, though not without taking a year off to deal with her illness. After Yale and several short-term jobs, Elyn was hired to teach at the University of Southern California Gould School of Law, where she was promoted to professor and given tenure. She married her longtime boyfriend, Will, who was as dedicated to serving her needs as any man possibly could be.
As Elyn lived with and against her illness, she became increasingly analytical and insightful as we can see in this cri de coeur: “I needed to understand what lay behind my terrible thoughts and feelings and how my psychosis served to protect me.”1p334 We might ask, How did she come to have these “terrible thoughts and feelings” in the first place? Whom or what did she need to be protected from?
Elyn gives little space in her book to her parents, but what she does say about them seems probative. Both parents were emotionally distant from their daughter: “[T]here was a wall of appropriateness between us at all times; in fact, we’d spent years carefully constructing it, I on one side with my particular set of tools, they on theirs, with the tools they’d chosen.”1p118
Had Elyn’s mother been “good enough,” in the Winnicott sense? And her father? At all stages of Elyn’s life, they seem to have been such vague presences, as if they were there, but not there for her. A family therapist noted that the parents had “made light of [her] illness and didn’t seem willing to accept its seriousness.”1p162 Elyn admits to being complicit in this cover-up: “I always did everything I could to hide its seriousness: I cracked jokes, and laughed, and was gratified when they did the same. It was our way of handling it. It was our habit—and every family has its habits. The levity and irreverence made it possible for us to be together without everyone falling completely apart.”1p163 Laing might have said that Elyn and her parents had denied their being to save their being—collectively as a family!
It eventually occurred to Elyn that a double trickery had ruled her life:
The illness—the entity—is always just off to the side, just barely out of my sight. But I know it’s there. And it tries to trick me into believing this isn’t the real Will, and this isn’t the real Steve [Elyn is describing Capgras syndrome, a delusion where she came to believe that her husband and closest friend were imposters], that reality isn’t reality, that I can kill thousands of people with my thoughts, or that I’m profoundly evil and unworthy.
At the same time, I’m trying to trick the people around me. I’m OK. I’m functional, I’m fine. And maybe, sometimes, this determined effort to trick them tricks the illness itself. It’s like one big con. Steve says he’s never seen anyone who fights as I do. I don’t consider myself a fighter (and I certainly don’t come across as ferocious). But if he’s right, then perhaps in my childhood, and in this push-pull with my parents, one can see not only the beginnings of my illness, but the seeds of my health and strength as well. If I’m a fighter, perhaps it’s because that’s who they taught me to be.1p327
Without directly saying that her parents had a role in the development of her psychosis, Elyn, perhaps influenced by Laing and Bateson,2,3 considers that possibility. The “push-pull” with her parents sounds like the kind of mixed discourse, comprised of 2 incompatible and emotionally conflicting signals that Bateson characterized as a double bind. Bateson believed that such a conflict, in a psychobiologically vulnerable child, can, through a “twisting” of the psyche, lead the child to fragment reality and create the kind of psychotic thought, behavior, and discourse that Elyn lapsed into.
One can imagine Elyn as a child being in what Laing calls a state of ontological insecurity—profound anxiety about who she was and how she was to live—putting on a false self—“I’m fine, I’m strong; I don’t need you”—and the parents, caught up in their own self-absorption and blindness, wanting to believe her pose, responding with the same emotional coldness that they appear to have shown throughout Elyn’s life. This nonresponse to Elyn’s needs may have deprived her of the nurture necessary to trust the world sufficiently to take on the challenges of each new developmental milestone, leaving her mind and brain primed for developing a chronic mental illness.
Elyn knew that she would most likely never be entirely free of her illness. However, during a hospitalization at the Yale Psychiatric Institute, when she was initially floridly psychotic (“People are controlling me, putting thoughts into my head”1p132), and on a high dose of antipsychotic medication, she began to see that she could do something significant to help herself. After weeks of miserable and contentious confinement, her psychosis began to lift, and Elyn had an epiphany:
And then something threw a switch in my head, and I got it. I got it. The only barrier between me and the door out was me. I simply had to stop it. Stop voicing the hallucinations and delusions, even when they were there. Stop babbling incoherently, even if those were the only words that came to my lips; no, no, it was better to be quiet. Stop resisting; just behave. Being in a psychiatric hospital is nonsense, I thought. I am a law student, not a mental patient. I want my life back, damn it! And if I have to bite my tongue until it bleeds, I’m going to get it back.1pp175-176
By being “quiet” Elyn meant not just putting on an act but making an effort to at least mute her psychotic constructions, until she could face the world more realistically without them: “Maybe I couldn’t keep the thoughts from coming into my head, but I could organize them, and keep them from getting out. OK, here I go.”1p176 For the first time, it seems, Elyn was asserting herself as an active agent against the illness itself, realizing that she had some complicity in the condition she found herself in, and some capacity to overcome that condition as well.
Near the end of the book, Elyn gives credit to Dr Freed, a psychoanalyst, who, she says, “helps me to understand how I sometimes use my psychotic thoughts to avoid the ordinary bad feelings that everyone experiences—sadness, rage, garden-variety disappointment . . . he tries to understand my psychotic thoughts as unconsciously motivated and meaningful (which of course they are).”1p325
As she brings her story to an end, Elyn is still taking clozapine and is told by her psychopharmacologist that she will most likely have to take some antipsychotic medication for the rest of her life. She credits both psychoanalysis and psychopharmacology for the progress she has made. “While medication had kept me alive,” she acknowledges, “it had been psychoanalysis that had helped me find a life worth living.”1p298 For someone so long and so tightly in the grip of a psychotically transformed world as Elyn has been, the challenge of breaking that defensive structure is probably in some ways akin to breaking an addiction to a chemical substance.
Elyn’s descriptions of her psychotic (and normal) experiences are taken here to be primary data, in the way that numbers, and the statistical elaboration of these numbers, are considered data in the empirical approach to studying psychopathology. Hermeneutic analysis of what Elyn tells us about her fall into psychosis and her efforts to have a career and a life—her story—reveals the phenomenon of one of the phenotypes of the heterogeneous illness we call schizophrenia. Her narrative draws us into the interior world of the psychotic person, territory that few clinicians attempt to access or assess.
1. Saks ER. The Center Cannot Hold: My Journey Through Madness. New York: Hyperion; 2007.
2. Laing RD. The Divided Self: An Existential Study in Sanity and Madness. Baltimore: Penguin Books; 1965.
3. Bateson G, Jackson DD, Haley J, Weakland J. Toward a theory of schizophrenia. Behav Sci. 1956;1:251-264.